Abstract: The aim of this study was to assess the role of damaged uterosacral ligaments and associated rectovaginal fascia in the causation
of rectocele, rectal intussusception, evacuation disorders and fecal incontinence. METHODS. 48 patients with various degrees of vaginal vault
descensus, clinical rectoceles and defecatory dysfunctions were treated by insertion of a posterior IVS (syn: infracoccygeal sacropexy), reconstruction
of the rectovaginal fascia and perineal body repair. RESULTS. Of the 48 patients with evacuation difficulties, 45 (94%) patients reported
complete normalization of defecation at both visits after surgery. Of the 27 patients with fecal incontinence, 18 (66%) reported cure, 5
(19%) >50% improvement, and 4 no change. Postoperative proctograms showed resolution of the rectal intussusception in 89% and 94%
reported completely normal defecation after surgery. CONCLUSIONS. Connective tissue damage to the anterior rectal wall supports may cause it
to sag inwards, "intussusception". The posterior sling creates a foreign body reaction which reinforces the damaged uterosacral ligament and
"reglues" the ligament's attachments to levator plate, cervical ring and rectovaginal fascia to suspend and stretch the rectal wall.Key words:

INTRODUCTION

Rectoceles are common findings in patients with intractable
evacuatory disorders. Typical symptoms are difficulties
to evacuate, incomplete evacuation, assisted digitation
to aid defecation, fecal incontinence, constipation, impression
of a pelvic mass, pelvic pain and dyspareunia. Occult
rectal prolapse has been found in 33% of patients with rectoceles
and defecatory dysfunction.1 Endorectal, transvaginal,
transperineal, abdominal or combined approaches are
treatment options discussed for symptomatic rectoceles. In
the presence of rectal intussusception, open or laparoscopic
rectopexy, with or without sigmoid resection, is still most
widely accepted. Although the anatomic results are mostly
good, all procedures widely lack functional improvement.
This is in particular true for posterior colporrhaphy 2 abdominal
sacrocolpopexy3, 4 and rectopexy,5 all resulting in
increasing defecatory dysfunctions.

In the normal pelvis, the sacrouterine ligament functions
as the most important supporting structure for the uterus,
vaginal apex and via the rectovaginal fascia, also for the
posterior vaginal wall and rectum (Fig. 1).
The rectovaginal fascia (RVF) attaches to the perineal
body (PB) below and levator plate (LP) above.6 The levator
plate is attached to the posterior wall of the rectum. Contraction
of the levator plate (LP) stretches both walls of the
rectum during anorectal closure and defecation.

In cases with disrupted rectovaginal fascia, a rectocele
may form. Due to distended sacrouterine ligaments, the
rectum can no longer be kept in its normal position, and
consequently proximal rectal parts may bulge into the distal
rectum causing intussusception (syn. internal rectal prolapse)
(Fig. 2).

According to the Integral Theory,7 dysfunctions of anorectal
opening (evacuation disorders) and closure (fecal incontinence)
are mainly caused by connective tissue damage in
the vagina or its suspensory ligaments. The explanations
offered above expand these concepts to the pathogenesis of
rectal intusssusception.

The infracoccygeal sacropexy ("posterior IVS") 8 procedure
belongs to the family of "tension free tape" operations.
An implanted polypropylene tape (Tyco Healthcare), reinforces
the uterosacral ligaments by irritating the tissues to
create a linear deposition of collagen. In contrast to other
methods which aim at fixation of the rectum, the infracoccygeal
sacropexy does not attach the vagina or the rectum
firmly to bony structures. It allows the surgeon to restore
the normal vaginal axis and the rectovaginal fascia anatomically
correctly, thereby reestablishing normal function.

We could see the following reasons for the use of an IVS
polypropylene sling in order to treat symptomatic rectoceles
with intussusception.

Baden and Walker pronounced their tent theory 8 stating
that if the top of a tent caves in, the walls may follow. This
translates for the vaginal situation that the first step in
the treatment of vaginal or even rectal prolapse should
be the restoration of a competent apical fixation, namely
restoration of the sacrouterine ligaments by insertion of a
polypropylene tape (posterior IVS). Important in this type of anatomical restoration is buttressing of the side walls,
namely the rectovaginal fascia in cases of a rectocele.9

The technique of posterior IVS follows the Integral
Theory surgical principles, that "restoration of function
follows restoration of form".10 As we did not only wish
to cure anatomical defects, but functional disorders also,
we believed that restoring the ligamentous supports of
the organs was more promising than other methods that
work by by stretching the organ and attaching it to fixed
structures, either the rectum (rectopexy) or the vagina
(sacrocolpopexy).3-5

Prior surgical experience with the Posterior IVS operation
(PIVS) (Fig. 3), in patients who had prolapse, and who
were also cured of their defecatory problems, suggested to
us that this principle could be widely applied in patients
with symptomatic rectocele and rectal intussusception.11

Our aim in this study was to prospectively test this hypothesis
by reconstructing the posterior zone anatomy, uterosacral
ligaments, rectovaginal fascia, and perineal body.9-11

MATERIAL AND METHODS

Between October 2001 and October 2004, 48 patients
aged between 39 and 86 years with vaginal vault descensus
I to III and clinical rectoceles presented with obstructive
defecation symptoms. All patients were asked to complete
a symptom focused questionnaire. After clinical assessment
they underwent single contrast defecating proctography.
Only patients with clear signs of rectal intussusception were
included in the study. Written consent was obtained from
all participants. Preoperative bowel preparation consisted of
oral X-Prep (extract of mustard leaves) on the day before
surgery and a micro-enema in the morning before surgery.
The anus was covered with a sterile transparent drape during
the entire procedure. All patients underwent the same type
of surgery, that was a 3-level repair of the posterior compartment
of the pelvic floor. In level 1 (apex) a posterior IVS
-tape was inserted as published earlier for reinforcement of
the sacrouterine ligaments, "Level 1 repair" (Fig. 3).9

In
patients requiring level 2 repair (Fig. 3), the rectovaginal
fascia was reconstructed conventionally in 28 cases using
mattress sutures to approximate the disrupted edges of the
rectovaginal fascia defect. In 2 cases the "bridge technique"
was used to repair the Level 2 defect.9 This technique uses
a cutaneous flap of the posterior vaginal wall to bridge
the distance between the ruptured edges of the rectovaginal
fascia in the midline. In 18 cases the rectovaginal defect
was restored by the insertion of a polypropylene mesh (Surgipro,
Tyco) underneath the rectovaginal fascia. Level 3
(perineal body) repair was performed in all cases where
the perineal body was loose.9 Care was taken to strictly
follow aseptic surgical technique. Surgery was exclusively
performed under general anesthesia. Single shot perioperative
antibiosis was provided by amoxicillin and clavulanic
acid. A vaginal pack and continuous catheterization were
kept for 2 days. Six to nine weeks postoperatively the single
contrast defecating proctography was repeated whenever
possible. During the same visit and again 6 to12 months
after surgery patients were asked to complete the same questionnaire.
Postoperative visits and the clinical assessment
were performed by an independent assessor.

RESULTS

Only 20 (42%) patients still had the uterus in place at
first visit. Hysterectomy was performed in 12 cases (60%)
because of concomitant uterine pathology. The postoperative
period was uneventful in all cases. After removal of the
Foley catheter, micturition was normal with only minimal
residual urine (0-80 ml measured by ultrasound). Discomfort
and pain resolved after 3 days, mainly after removal
of the vaginal pack. From that time on patients reported
just minimal pain, sufficiently managed by oral analgesics
(Naproxen) on demand. Patients returned to normal food on
the first postoperative day and were discharged on the 7th
day after surgery.

Functional results: All patients preoperatively complained
about obstructive defecation disorders, and 45/48
(94%) patients reported complete normalization of defecation
at both visits after surgery. They stated that no obstruction
was felt any longer, no incomplete emptying, no pain
and no incontinence or soiling. 3/48 (6%) felt unchanged
after surgery regarding the ability to pass stools. However,
these patients showed normal defecating proctograms at
control.
Of the 27 patients (56%) who complained of fecal soiling,
scoring on a numeric rating Scale (NRS), reached a total of
119 (mean 3.6). Of these, 18 (66%) were cured (NRS 0),
5 noted a very significant improvement (NRS <50%), and
the other 4 reported no change. Of the 13 patients (27%)
with pain in the lower pelvis (total NRS 57), 9 (71%) were
cured (NRS 0), and the others reported a 50% improvement
(NRS<50%)

Anatomical results: In all patients the vagina showed
normal width and length and was normal in its axis. POPQ
analysis showed median postoperative C - point at -9 (-7 to
-11).

Radiologic results: Postoperative single contrast defecating
proctography was obtained in 19 patients (40%). 17/19
(89%) showed a normal anatomy of the rectum and no
intussusception (Fig. 4b). In 2/19 (11%) patients a minimal
residual intussusception could be detected. However, all
rectoceles disappeared. In all other cases patients denied to
undergo this uncomfortable examination because they felt
completely cured, especially when they lived too far from
our hospital.

Complications: Intraoperative: In one patient during dissection
of a large rectocele the anterior rectal wall was
incidentally incised. After primary double layer suture the
procedure was carried on according to standard protocol. In
another patient we found the IVS tape inside the rectum on
the right side after completing the procedure during routine
rectal examination. After visualization by rectal speculum
the perforating part of the tape was excised, the two little
holes were sutured by one single stitch suture each and the
patient was put on postoperative oral opium and prolonged
antibiotic prophylaxis for 3 days.

Mesh erosions appeared in 2 cases and were treated by
excision of the eroded tape in an outpatient setting. We did
not see any haematoma, abscess formation or any other perioperative
complication.

DISCUSSION

The concept of "tension free" reconstruction of distorted
anatomy using intravaginal polypropylene slings has been
shown to be successful for the treatment of various pelvic
floor disorders in the female.7-12 Until now it has been
used to treat stress urinary incontinence, as well as various
degrees of uterine and/or vaginal descensus or prolapse.
These minimally invasive techniques aim to treat impaired
pelvic floor function by restoration of anatomy.

The functional results of existing rectopexy regimes for
these cases are not only traumatic, but widely unsatisfactory.
5 Our results appear to confirm our hypothesis that the
sacrouterine ligaments are an essential structure for normal
function of the anorectal complex.7 Furthermore, reinforcement
of the sacrouterine ligaments by insertion of a posterior
IVS tape is successful in restoring both anatomy and
function, as demonstrated radiologically in Fig. 4b.

This "tension-free" approach sets out to mimic normal
anatomy without distortion, by repairing all the anatomical
levels which contribute to anorectal opening and closure.9-10
This 3 level approach does not alter the geometry or the axis
of the pelvic organs, and would appear to offer a more anatomical,
and therefore, more functional treatment plan than
isolated rectopexy or sacrocolpopexy. The latter only perform
a level 1 repair. We firmly believe that stretching and
over-correction of the organs should be avoided. This is certainly
the case for rectopexies. During rectopexy a distance
of about 10 cm of the rectum is functionally disturbed by
fixation of the rectal wall onto the sacral periostium. This
may be the reason for the reported poor functional results
of this procedure. The same reservations apply for sacrocolpopexy,
a method which bears the problem of over-correction
if fixated to the sacral promontory. Using posterior
IVS avoids the danger of over-correction, since neither the
rectum, nor the vagina are fixed to bony (and therefore
immobile) structures during this procedure. Above all, organ
mobility, a key element in pelvic floor function, can be
maintained, as described in the Integral Theory.9-12

Compared to rectopexy, posterior IVS is less invasive and
thereby less susceptible to surgical complications. In a large
series,13 33% operative morbidity was reported after rectopexy.
Most complications occurred in the early postoperative period,
including severe complications like bowel obstruction and
ileus, but also late complications and fistulas occurred. In our
series we did not have a single severe complication. Erosions
(4% incidence) and their accompanying vaginal discharge may
sometimes be disturbing to the patient, but really, they are a
minor problem, and usually easy to treat.

We were not successful with this approach in 3/48 patients.
Interestingly, these patients showed normal anatomy on defecation
proctograms. Our anatomical concepts (Figs. 1 &
2) do not seem to explain such normal findings. All three
patients were sent to a specialized gastroenterologic unit for
further workup, with no success to date.

In our series hysterectomy did not appear to be a factor in
clinical success or failure.

Cure of posterior zone symptoms such as pelvic pain is
explained in previous works.7, 10, 12 The simultaneous cure
of fecal incontinence and difficulty with bowel emptying is
theoretically addressed in Part 1. The uterosacral ligament
and perineal body are key functional insertion points for the
backward/downward vector forces, and also, the rectovaginal
fascia. Lax insertion points may invalidate these muscle
forces, disabling the rotation around the anus necessary for
anorectal closure, and also, the opening out of the anorectal
angle during evacuation.

As concerns cure of FI, this work differs significantly
from Studies No 9,10 &11 in this issue. All patients undergoing
surgery had symptoms of obstructed defecation and
radiological evidence of rectal intussusception; 56% had FI,
and 85% of these were cured, or very significantly improved
by a posterior sling repair limited exclusively to the posterior
suspensory ligaments, the uterosacrals. The study emphasizes
the importance of investigating such patients holistically:
assessing evacuation and rectal wall intussusception,
as well as incontinence. A major improvement (85%) in FI
symptoms was achieved with repair only of the posterior
ligaments. Whether the cure rate would have been improved
with a midurethral sling is not known. Neither do we know
how many patients had evidence of muscle damage, as this
was not tested.

CONCLUSIONS

With regard to "obstructed defecation", rectal intussusception
and FI, we find that this new approach offers clear
clinical advantages compared to more conventional procedures,
minimal pain and trauma, rapid recovery, and fewer
complications. It is a correct anatomical approach with no
unphysiologic fixation of the rectum. Thereby the function
of defecation is restored and the vast majority of our patients
felt rapid normalization of stool habits immediately after
surgery. Although the number is small, the demonstrated
results are promising, suggesting this new approach should
be pursued further.